Case Report

A 59-year-old woman with a past medical history significant for anxiety and acid reflux presented to the hospital with acute-onset hematemesis after eating 2-day-old Chinese food. The patient did not drink alcohol or use illicit drugs. She had no recorded episodes of hypotension or syncope and no history of vasculopathy or vasculitis. On admission, she was afebrile with normal vital signs. The patient’s abdomen was tender to palpation. She had an elevated white blood cell count (20 g/dL) and normal hemoglobin. Abdominal computed tomography revealed diffuse gastric wall thickening, edema with perigastric inflammation, and upper abdominal free fluid, but no evidence of pneumoperitoneum or significant gastric distention. It also showed patent gastric and mesenteric vasculature without radiographic evidence of vasculitis. Blood cultures grew beta hemolytic Streptococcus, and the patient’s stool polymerase chain reaction was positive for Clostridium difficile. Anti-nuclear antibody was negative, and no other vasculitis workup was performed. Upper endoscopy to evaluate hematemesis showed the entire stomach to be dark, purplish-black with necrotic, bleeding tissue; no healthy appearing tissue was present (Figure 1). Biopsies of the stomach confirmed acute mucosal necrosis consistent with ischemia. The patient was treated with bowel rest and broad-spectrum antibiotics, and she recovered without the need for surgical intervention.

Gastric ischemia or phlegmonous gastritis is a rare cause of hematemesis with only 37 reports in the literature from 1973–2003.1 In a patient without vasculopathy or toxic ingestion, infection leading to necrotizing gastritis should be considered. Bacteria such as beta hemolytic Streptococcus, as well as strains of Escheria coli and Clostridium, should also be considered.2 Other risk factors that have been described include arterial embolism, gastric volvulus, iatrogenic gelfoam injection, bulimia nervosa, and small bowel obstruction with gastric distention.3 Acute ischemia in otherwise healthy individuals has been described but is exceedingly rare.4

Disclosures

Author contributions: RB Vance wrote the manuscript. CA Mayorga reviewed the manuscript and is the article guarantor.